Utilization Review Specialist

Verida Inc • Villa Rica, GA

2d • $17 - $18

About The Position

The primary responsibility of this role consists of reviewing member transportation requests that are over the contractual mileage guidelines. This role involves reviewing and making approval/denial determinations for all member transportation requests that are outside of the geographical mileage guidelines and reviewing requests to non-covered Medicaid services and/or locations. The specialist will also review for approval/denial determinations for facilities wishing to participate in the organization’s Subscription/Standing Order Transportation Program, process subscription/Standing order transportation requests from approved facilities for NEMT, and investigate transportation provider complaints lodged against Medicaid members during transportation. Issuance of Member Warning Letters as warranted is also a key function. The role is responsible for completing three departmental reports: daily denial letters, member no-show letters, and a monthly denial summary. Additionally, the specialist will run the Monthly Denial Summary Report for covered regions and send it to the client.

Requirements

• Knowledge of Medicare and Medicaid, community resources, dialysis, and the nursing home placement process.
• Must possess entry to mid-level proficiency in Microsoft Word and Excel.
• Excellent written and verbal communication skills.
• Possesses and demonstrates multi-tasking skills in a high-stress environment while working with multiple internal departments, as well as external entities.
• Analytical thinker with good judgment.
• Well-organized, self-directed individual, who is flexible and takes direction well.
• Possesses a high level of interpersonal skills to handle sensitive and confidential situations.
• High School graduate or equivalent.
• 2 years of customer service experience and or employment in the healthcare industry.

Responsibilities

• Reviewing and making approval/denial determinations for all member transportation requests that are outside of the geographical mileage guidelines and reviewing requests to non-covered Medicaid services and or locations.
• Review for approval/denial determinations for facilities wishing to participate in the organization’s Subscription/Standing Order Transportation Program.
• Process subscription/Standing order transportation requests from approved facilities for NEMT.
• Investigates transportation provider complaints lodged against Medicaid members during transportation and issuance of Member Warning Letters as warranted.
• Completing the three departmental reports: daily denial letters, member no-show letters, and monthly denial summary.
• Run Monthly Denial Summary Report for covered regions and send to the client.

What This Job Offers

• Career Level: Entry Level
• Education Level: High school or GED